Jeanine McGuire, MPT, CWS: Hello, and welcome to this Innovation Theater, sponsored by Halyard in collaboration with PAWSIC, the Post Acute Wound & Skin Integrity Council. I'm Dr Jeanine McGuire, a licensed physical therapist, certified wound specialist, president of PAWSIC, and also the chief clinical delivery officer of Tissue Health Plus, and I will be your moderator for today's session. 

Today, we have Cathy Milne, who is an advanced practice wound ostomy incontinence nurse and provides care to patients across the continuum in acute care, long-term care, home health, and outpatient settings. Cathy is also a founding member of the Coalition for At-Risk Skin and a board member of PAWSIC. Today, we are thrilled to have Cathy Milne with us to present Personalized Chronic Wound Management: Leveraging Patient Insights for Optimal Outcomes. Cathy.

Catherine T Milne, MSN: Thank you, Jeanine. First of all, I am so honored to be doing this. This is one of my passionate subjects I really like to talk about. I do want to thank both Halyard and PAWSIC, which is the Post Acute Wound & Skin Integrity Council, for having me today. Please support these organizations and vendors because they are giving you something that you can access for free. So, thank you again very much.

Here are my disclaimers, and here are my objectives for today. I think we always talk about multidisciplinary care for wound management and how we really love it and it's supposed to be what we strive for. The question is, do we really practice it? And I think when we practice it, we always think about other providers and other professionals, and sometimes we forget the patient. So, I'm going to talk about patient engagement and how to improve that engagement and, ultimately, patient care. And we're going to talk about some of the clinical data that goes along with that, because data is important. And then we're going to talk about some case studies of some of my patients that I actually learned a lot from but really enhances the multidisciplinary team and patient engagement, because that's what really we always strive for. 

So, let's talk about multidisciplinary care for wound management. Now this is a slide that a lot of us see specifically to the diabetic foot ulcer, But I think if we started looking at some of the other wounds that we have now, people with venous insufficiency, they don't have a high mortality rate directly. But think about the morbidity. They have multiple hospitalizations. They have cellulitis. They have social withdrawal. They have lots of problems. People with arterial disease without diabetes have a very high mortality rate, and when we really look at the pressure injury data for stage 3s and stage 4s, yeah they may get better, but it does take a toll on them. And when you start looking at some of the more severe cases that now we're probably considering skin failure, once we have a definition and an ICD-10 code, that when you look at the long-term data, their mortality is usually within a year if they survive that initial event.

Catherine T. Milne, MSN: So, diabetes is probably one of the biggest things we all deal with. Yes, they may have a pressure injury and diabetes. They may have a arterial disease or an atypical wound and diabetes. So, the morbidity associated with diabetes is greater than some cancers. And some of the times, I feel like I can't get through to my patients, and I get very frustrated because I'm trying to let them know how serious their foot wound is. And it's just, “Well, I'm not really going to offload. I'm not going to do this. I'm not going to do that.” And so then I do the scare tactic and I say, “If I told you you had lung cancer, what would you do?” “Oh, well, I would go to chemo, I'd have radiation, I'd have surgery.” And I say, “Well, guess what? Your chances of dying is as great, right? You have just a slightly less chance of having a major amputation than dying of lung cancer. And it is greater than having all cancers. So, you really need to think about this.” So. And then sometimes that really does help engage them, although that's not the way I like to engage them. 

So, teamwork is really essential for patient care. I think we all know that, and we need to identify all those providers. I think it's really hard to have– We can all find a team member. We can find a nurse, we can find a physician, we can find a infectious disease doc, a vascular doctor, but it's that molding of that team together. So, there's mutual respect for each other's ideas and a common goal with the patient that really puts that patient at the center. 

So patient engagement really started being the focus of health care when the World Health Organization had this declaration. It's called the Declaration of Alma-Ata. And it basically, there's a lot of requirements about, yes, we need a multidisciplinary team, and everybody should have health care. But there's a few paragraphs in there that's really compelling. And it says that every patient has the right to be planning of their care and also involved in their care and it also says they have a duty to be planning and implementing their care. And there's actually two different things. Yes, we have the right to do it, but they also have a responsibility to participate in planning in their care and implementing in their care. 

So they really need, we're saying to everybody you need to be very active, have your patient be active in their medical decision-making. And, you know, more broadly, the WHO is saying we need to get patients more involved in planning these health care systems. I think we all know of the frustrations we feel trying to get our patients through the system, and think about being a patient who is not in the system and doesn't even know how it works. So, they really need to help us design a better health care system and help us deliver that health care system. So really, it starts with us. It's really a ground-level effort, and we can build this.

Catherine T. Milne, MSN: So, I like to call this the terms of engagement. It doesn't matter where you are in the world, we call it the same thing different ways, right? Some of us call it patient-centered care. Some of us call it patient decision-making. Some people call it patient empowerment. Some people call it shared care. And the one that I still have problems with is when places call it “participatory medicine.” Because medicine is really a professional way of making somebody do the medical model, which is a lot of diagnostics and medication-oriented. Although I do say that since I've been practicing for a long time, I am seeing the shift of the professions really going towards patient-centered care. When I was educated as a nurse, it was the first month of nursing school, we learned about the patient is the center and we had to learn all these nursing theorists and stuff like that, which I thought was very boring at the time but now really, really appreciate. 

So, the bottom line is you have to involve your patient, right, in the management of their own care. So now if you think about going to, let's say, a banker, if you hire an electrician or a contractor, or an accountant, you're really using those professionals as a consultant, right? So, you are asking them for their advice, they're telling you the pros, the cons, the goods, the bads, maybe how much it costs, how it's going to impact your quality of life. We don't allow our patients to do that. We have more savvy patients. I'm not saying that every patient doesn't do that, but I think we need to open up the door and say, “I am your consultant, and I will tell you the good, the bad, the ugly, and we have to work together,” because that's what consultants do. And so we have to first recognize that our patients have choice and control over the health care they receive. 

And to do this, we need to give them both resources and education. And we have to do it in a number of different ways, whether it be video or reading or hands-on tasks, we have to figure out how they're going to incorporate the knowledge and resources that we want to give them. But the whole goal here is not– We have a need as health care professionals to heal the patient. That is our mission, right? But it may not be the mission of our patients. So we need to identify and focus on improving the patient's disease in the context of their own life. If you think about lymphedema, that is a chronic disease that will never go away. And they have to learn to manage it for the rest of their life. So we have to think of all of these wound care issues pretty much the same way. And if you've listened to David Armstrong, he's the first to really say diabetic foot ulcers never go away, they just go into remission. So if we have that framework that will help us help engage our patients. 

Catherine T. Milne, MSN: So how do we engage our patients in their own care? Well, you know what? We need to look at patients individually. And so we should be looking– These are social determinants of health. And now we do have quality measures, if you're a provider, looking at social determinants of health. And actually, I was speaking with somebody the other day who is in long-term care. This person had a state survey in and I said, “Oh yeah, so what are they looking at this year?” And she said, “You know one of the things they're looking at, besides patients returning to the hospital, was social determinants of health and how we are identifying them and accommodating and/or managing them.” So it's nice to see that we're starting to think about this. 

However, if you are working in an outpatient office or maybe in a nursing home or short-term rehab or anywhere outpatient or actually even inpatient, do you have the time to tease out some of these social determinants of health? It's really difficult because of the pressures that we have upon us. So take the pressure off. You may not have to get all this information at that first visit, but you might want to figure the first thing out about, what's their daily routine like? What do they want their daily routine like? And their medical history, and then you can delve in and further episodes or either be visits or interactions with the patients, the other things. If you have not seen Janice Beitz, who is a nurse practitioner certified in wound care, WOCN, and WOCN Fellow, she has done some wonderful work in terms of the epigenetics of people with chronic wounds and how the socioeconomics and lifestyle of their grandparents is now affecting them now. Even though they may have had a very nice life, it still will affect them and almost re-hardwire them. And some of them don't heal because of some of the previous traumas that are their grandparents’ or have had. I think I've read a little bit about the impact of what the hurricanes will have on future generations too. So we have to think about that also. 

So if you ask your patients, so what are they saying, those with chronic wounds? Well they're saying, “You know what, we have poor communication with our provider. And we get a lot of different information from different people. So the home health nurse says this, the outpatient wound clinic says this, the acute care nurse says this, the primary care doctor says that.” And so that is, I think, one of the most frustrating things for our patients, because they want to trust everybody, but they now don't know who. And so they're very overwhelmed at not only the complexity of chronic wound care, because it's a lot more complex than the majority of illnesses out there that they see their primary care for. But you add that extra layer of complexity with the health care system. It's a little bit easier in other countries, but clearly in the US we've made it very, very complex. And everybody, I don't care where in the world you are, we have limited resources. Every country struggles with referral and treatment delay. I think that there's a misnomer that you can get instant care here in the US. And a lot of times you can't for some of these more advanced products just based on the laws or the insurance guidelines. 

And then the one that I think is one of the most disturbing things is the perception that amputation is an easier alternative to manage a wound or try to save their limb. And that one, that statement, when I heard that, made me really sad. And when I was talking to a patient just about 3 weeks ago, I was talking about his wound and so on and so forth. And he said, “You know, everybody I've been to just wants to cut this off.” And I'm thinking to myself, “That still happens today?” And yeah, it does. And that's very, very sad. And I really don't know where that comes from, from a health care provider's perspective. But I think it's something that we need to look upon ourselves and address. 

Catherine T. Milne, MSN: So how can we do better? Actually, this came from Caroline Fife. She has interviewed her patients. She did a wonderful job writing this blog up, and it's just absolutely great. And I think we should hang it up in wherever we are—by the nurse's station, in the bathroom, in your car, wherever. Because here are things that patients really want, right? They want to be touched. They don't want somebody to come in, look at the wound and then walk out. They want to be touched. And so one of the ways, a great way to engage a patient is, maybe you don't have time to do the whole dressing, maybe start that leg wrap or do an examination. We probably can look at a wound across the room and go, “Oh, yeah, I know what that is.” But you know what? It makes the patient feel really good that you are doing a physical examination. In fact today, in Anne Landers, in the newspaper, actually it wasn't the newspaper, it was online. So this person wrote in and said, “You know, I went to a new doctor and I was supposed to get a physical, but he didn't touch me.” And she was very disappointed. And so now she has no trust in that provider. 

They also want to be listened to. They want to tell their story. Now, a lot of us have heard the same story over and over and over again. Some of us don't have time to listen to that story. Some of us are at our computer going, "Yep, yep." And so we're really not listening. 

So one of the strategies I do, at least in the outpatient department, is when the nurse goes in to get that history, I will come in usually about 5 minutes after and I just sit down and I listen to the nurse ask the patient the question, because it helps me determine where I want to go in further questioning. But they think it's important that you're listening. And it's hard not to rush, and that's something that we all need to negotiate with our bosses because they have a productivity suggestion that they really want us to keep on time and get to see as many patients as possible. And we have to convey to the patients that, “Your treatment, your wound, your lifestyle, your circumstances are different.” 

And so just acknowledging that they're an individual, even though we're going to do the standard of care, like for a venous leg ulcer, we're going to work them up. We're going to see if there's anything structurally that we can manage. And then compression is that mainstay. So everybody's going to get compression for the most part, but you're going to say, “Well, there's different varieties and types and what's going to work for you.” And then there's a lot of negotiation. And that's the partner piece. So, and it's okay to say, “We're going to start with this, but we may have to tweak this down the road.” It's perfectly okay, and they need to know that that first treatment may not be the best, but it's something that they think that they can manage with, and then we can go forward with. So these are what our patients are saying. We just need to be able to incorporate it into our daily practice. 

Catherine T. Milne, MSN: So when you look at different countries, this was done by Zena Moore. Zena does a lot of patient engagement research and work. And so you can see that for the most part, both China and the USA have the most engaged patients. And as you look further down, really, Germany, France have the lower engagement areas. But for the most part, you're 50-to-75%, which we would like 100%, but at least we know that we can move this bar a little bit. 

Now, Zena's work actually has come down to the ability to say there are really 4 types of patients. And if you know what type your patient is, you can change what you do and your approach so you can get your patient engaged. So the 4 types are the unaware, the reliant, the reassurance seeker, and the self-sufficient. So the willingness is very high for the self-sufficient and very low for the reliant, and there's a lot of reasons for the reliant to be that way. So let's talk a little bit about these in more detail. 

So the patient who is self-sufficient, these are the people that either you really love or you love to hate, right? Because they come in, they've already done their entire literature search, they've gone through the internet, they've done their research, they know everything and probably maybe even more than you do about their wound, their treatment, the underlying problems, so on and so forth. And they really want to be involved. And they are very motivated because this wound is preventing them from doing what they really want to do. The nice thing about these people is they are physically able to help out. And I love working with these people. But the interesting thing is, and one of the things we need to be assessing for is, these people have a very large social support network. So that can be really, really telling about where they're going to be on this grid. They don't necessarily trust us the way we want them to, which is why they've gone and done all that research. So being very consistent working with your team members to make sure everybody has the same story all the time actually can be very, very helpful. And these are the people you're going to want to carve out a little either extra time or some of that visit just to talk about this wound and any new information that you may know. 

Catherine T. Milne, MSN: Okay, the reassurance seeker. This person really has the ability to do this, to take care of their wound, but they're nervous, right? And they have a smaller, and actually a pretty small, social network, but they trust us, right? So they come in like, “Oh, you know, I wish I could do this,” or “Can I help you do that?” or “How can I do things better? I'm trying really hard.” And so they just want a pat on the back saying “You're doing great. I'm glad you did X, did Y. Did you try something new?” And even though it probably isn't something that you would have recommended, if it didn't hurt them, you have to praise them for trying. And these people ask for a lot of advice and education. So again, you have to figure out what is the best way for them to get that information, whether it be visual, audio, or written. And these are the people you want to cut out and carve out some time during that visit or that interaction to discuss any fears or concerns they may have. You know, a lot of it may be, “Oh, I want to go see my granddaughter's wedding,” or “I paid $2,800 for a cruise and it's in three months and I want to make sure I don't lose my money” or “I want to be able to do this.” So once you understand their fears– And I find my patients with diabetes, when you say, “What's your biggest concern about this wound?” and they say, “My grandmother had a wound similar to this and she lost her leg and then died.” So then you know where they're coming from. So you need to work with that. 

And when we keep on moving on, the unaware. So they are very passive people. They don't know that they can participate. And some of this may be an upbringing where they've been told that the health care profession knows everything, they'll tell you what to do, just do it. Don't question anything, just comply. But we need our patients to take care of their own wounds as much as possible and be part of this whole multidisciplinary team. These people also have a really small support network. And you also find the unaware are people who really have no cognition about their own body, either through denial or another mechanism, and they see us as the last resort. 

I actually had a patient about a month ago who didn't have access for transportation, saw that he had a leg wound, wasn't calling—he had a very small support network, didn't call his primary care physician, didn't call anybody he knew, didn't call. He just said he called a senior health outpatient toenail clinic, and they told him to call something else, but “Ah, you know, nobody's going to answer.” And so he waited til the last resort. And these are the people that show up in the ED, and we need to identify them before they do because it costs our health care system a lot more money to take care of these people. They don't really follow advice. They're least likely to make health care improvements in their life and change their lifestyle. And so these are the people that you just want to say, “I need you to get engaged.” I really actually think that some of our diabetic patients, we do know that there's some cognitive decline even with pre-diabetes. So we need to start talking with our patients way, way before, but it's a constant repeating, “We need you to understand what you can do to help us make you better.” 

Catherine T. Milne, MSN: And then there's the reliant. We all have those kinds of patients too. They physically or mentally can't participate. If they can physically or mentally participate, they will. But you really need to do more work with their support system. And I call that the circle of care. 

So these groupings are really fluid. And I love this picture because this is a patient of mine. She had a wound on her foot, and she kept on saying “Everything's fine.” She was really not that engaged, and she would sometimes try and sometimes not. And then one day this thing really kind of blew open. And I took my Q-tip and put it from the plantar aspect and I said “Watch what happens to the top of your foot.” And so up went through the Q-tip and she said, "Oh my gosh, I really need to control my blood sugars better. Oh my gosh, I really need to eat better. I may lose my foot." 

So these groupings are fluid. So don't just judge somebody as reliant or at the nervous Nelly person and then think they're going to stay there, because a lot of them do have “Aha” moments. 

So what are the benefits of a multidisciplinary care team for wound management? Well, there's this great clinical study that looked at improved healing for pressure injuries. So this study looked at conventional nursing care compared to a multidisciplinary team-based care for pressure injury wound care. So the control group just was what nurses do all the time: We're going to give you the standard of care with pressure redistribution surfaces. We're going to turn you on an individualized plan. We're going to tell you to eat better and manage your pain. And we're going to do the dressing. And so that's really like one from the provider to the patient. 

And then the study group really got that multidisciplinary collaborative care going. So you had nursing, you had physical therapy, you had nutrition, you had various physicians involved, you had administration and the setting involved. And so it's just not the people at the bedside, it's the people that also support the people at the bedside that need to be part of this multidisciplinary team. 

Catherine T. Milne, MSN: So what they did here was they established the intervention team, they clarified responsibilities, and really key here was they set up this group chat, and they organized communication. So once that communication was set, you could see who was involved here, but everybody had a role and each decision was communicated with the team in that group chat along with consultations for anybody else they felt that would help things out. And then—so this is the group itself, has to respect each other—nd they were able to manage that patient through group chat, telephone, and return clinic visits. 

So, what was the rate of healing in this multidisciplinary group? 96.77% versus 80.65%. Now, this is a high rate. If you look at all wounds and not just pressure injuries, you are looking at about a 67% healing rate. There are 33% of those wounds that will never heal, right? So this is a very impressive healing rate for pressure injuries. Now, they did find that there was no significant difference in economic factors, social determinants of health, or physical factors, but it was the patient's satisfaction with this intervention group or the study group that was much higher. 

And so, you know, when your patient’s satisfied, I think they're willing to work harder with you. And then that really, I think, is key because once you've engaged that patient and they are more satisfied, they're more willing to help and do things for themselves and help plan and implement their own care, which is, again, what the World Health Organization was saying. Plan, implement, and they have the duty to implement their own care. And this just really kind of shows that. 

So the other interesting thing is that we've seen studies like this in intensive care units, way back when intensive care units first started back in the 70s. In the early 80s, they did studies about the multidisciplinary team, when it worked well in the critical care, they had less mortality and higher survival rates. So we do know, whatever setting you're in, that multidisciplinary care leads to improved satisfaction, which really engages that patient. 

So let's talk about some of the case studies. Jeanine, I may ask you for some thoughts here. 

Catherine T. Milne, MSN: So this is a guy that was found on his floor of his home. He fell, he had a syncopal episode. He was on the ground for about 32 hours. He had the usual things that we see with these types of patients—rhabdomyolysis, they found a rapid Afib, dehydration, and then his buttocks was completely black. 

So again, multidisciplinary. So the wound care team– The nursing staff assessed him and they called the wound care team, wound care team called Plastics, we called Nutrition. We got all the services in place. We had a little patient huddle about what we want to do for this man. And he really was saying, “I'm going to go home,” and we're thinking to ourselves, “This man is not going to be able to go home right away.” We would love for him to go home. So we all had to be on the same page so he would have enough buy-in to then go through short-term rehab, and then eventually he went to long-term care. 

So he refused a diverting colostomy, and you can see that this was a very problematic in this patient. We actually, we were lucky enough to have a psych liaison clinical nurse specialist, and she delved into a lot of the reasons why he didn't want to have a diverting colostomy, but he still refused. And then, of course, he was discharged to the local nursing facility. Jeanine, do you have patients like that? 

Jeanine McGuire, MPT, CWS: Absolutely, I think we see individuals not only with that disposition, but also with the severity of this wound and the challenges that this situation presents. 

Catherine T. Milne, MSN: Right, so let me show you what happened to him. So this is day 30, because once we got him to the long-term care facility, or short-term rehab wing of a long-term care facility, we, after the debridement, we had started him on negative pressure and wound therapy, you can see that here. We actually got Nutrition involved, because we need to get this guy in a really good bowel program. We had Nursing involved, we got Physical Therapy involved to do some advanced modalities such as pulse lavage and diathermy on him. 

But you know what, one of the things that we also had to do was– And when we always think of therapy, we always think of the physical therapist. You know, the occupational therapist has a lot to offer here in terms of—and what I learned from her in this case is this guy's going to need a lot of upper body strength. He had very, very, he had nerve damage from this wound. He was very weak, and there was, he was not going to walk for a long time. And if he would ever walk again, he was going to need a lot of strength to get up and go. So any thoughts on this? 

Jeanine McGuire, MPT, CWS: Yeah, circling back to everything you said about understanding our patient. So the first thing I'd want to really figure out as a team and as a physical therapist: What is his goal? What's most important to him? Clearly, he didn't want to become a nursing home patient. But now that he's in this situation, how can we motivate him? So I'd really want to get into his head or work with social service and understand what's most important to him so we can really relate our wound healing goal to his goal. So that would be my first thought. 

Second thought from a PT perspective is even though we agree this is not a pressure injury—this occurred from the fall, right?—so that being said, this is still in an area that's going to sustain pressure by the sheer nature of our anatomy. And I think that he has these other risk factors from the bioburden exposure and also, just he’s on anti-coags from the AFib so that's going to make his tissues more friable. All that being said is, all the time this man might be sitting or lying in a bed is going to probably cause some other force to this wound, whether it's pressure or shear. And so I'd really want to think about the surface I’d have him on, the mobility program I get him on, and then other modalities, maybe even e-stim when the time is right, to help get him in a better state of proliferation. 

Catherine T. Milne, MSN: Right, and a lot of us are inhibited by the resources that we have available to us too. So, and if you had a patient like this in home health, it's even more difficult because we're only there in for a visit and there to stop by when you walk by the room and go, “Hey, let's give you a little, you know, help you turn over. Are you doing your exercises?” That kind of stuff. 

Jeanine McGuire, MPT, CWS: Yeah.

Catherine T. Milne, MSN: So that makes it more difficult. 

So, by day 50, we're starting to shrink. We're getting better healthy tissue. We really had a lot of time, a hard time with his diet. We need food to build tissue, and he didn't like the food. And actually, what we ended up doing is that we called in the pharmacist. So because really a lot of his appetite issues were related to his medications. He just didn't have any good taste. He'd been on tons of antibiotics in the hospital. He'd been treated at this point for osteomyelitis, and he just didn't have any appetite. And of course, you're not moving as well as you're used to, so you really don't have that appetite. So we actually did reduce a lot of his medications.

And we actually considered using a medication to help stimulate his appetite, which was also an anti-depressant, because by this point, he was very, he was depressed because he knew that it was going to be a long time before he could ever get home.

And then day 120, day 150, we're just keep on going here. We actually tried to engage him a lot more by showing him pictures. And so we could say, "This is what you started out with." And of course, he wanted to see the pictures. We asked him first. We didn't show it to him and put it in his face and say, “Here, look.” But he actually got encouraged when he actually could see things getting smaller. And so he started working harder because he could see progress. Do you find that in some of your patients, Jeanine?  

Jeanine McGuire, MPT, CWS: Yeah, pictures are amazing motivators. So long as they're willing to look at those photos, a lot of times these wounds are on areas of their body they can't easily see, whether it's their backside or bottom of their feet. I think we should be as transparent as they would like us to be and make them part of the team. 

Catherine T. Milne, MSN: Right. So if anybody has ever heard Jeanine speak before, she says, “We should be doing pictures on every patient because the patients are doing pictures of their wounds. So we should be too.”

Jeanine McGuire, MPT, CWS: That’s right. 

Catherine T. Milne, MSN: Okay. And this is what he looks like a year later. So he's got some, still macerated, hyperkeratosis. And, at this point, he was willing now to go back to Plastics to get a really good debridement. And then actually he went home after 2 years, so it was a long haul for him. We were really proud of him. 

Jeanine McGuire, MPT, CWS: Wow. 

Catherine T. Milne, MSN: So 62-year-old male, deep tissue injury after being left on a bedpan. So part of the multidisciplinary team was really mad at another team member who is not part of the closer group but still part of the organization. Because sometimes you do all this great work. So you sometimes have to not– It may not be, your teamwork may have to be with other team members or other associates within that organization and not necessarily with this patient. But you can see here, we have a lot of edema. You can actually look at the hemorrhoids down at 6 o 'clock there. He has a lot of buttocks edema. So we had to address that along with the pressure injury. 

And you can see he does start to evolve. So he needed all the standard things that we do, we didn't need to call Plastics, but what we ended up doing is really working hard with the primary care physician to think about how we can reduce edema. And the physical therapist came up with this great—I don't want to call it a contraption—a device to help reduce edema, actually a lymphedema. We got a diagnosis of lymphedema, worked with a lymphedema therapist and got garments that would actually go up to his waist. So we were able to reduce a lot of that edema. 

And you can see we also would need the surgeon on this case too. And eventually we did a great scoop out, and he went on to close. Any thoughts on this case, Jeanine?  

Jeanine McGuire, MPT, CWS: That's amazing. You said this was a patient in a nursing home? 

Catherine T. Milne, MSN: No, I just, I don't want to say the setting because this happens in every setting. I've seen this in a– 

Jeanine McGuire, MPT, CWS: It does happen in every setting. Okay, that’s fair. 

Catherine T. Milne, MSN: I've seen this in assisted living…

Jeanine McGuire, MPT, CWS: Yes.

Catherine T. Milne, MSN: …because some of those patients really need skilled care. 

Jeanine McGuire, MPT, CWS: Yeah.

Catherine T. Milne, MSN: And I've seen this in, yeah, it happens everywhere. 

Jeanine McGuire, MPT, CWS: It could probably happen at home. So the one thought I had when we see something like this is I would refer the audience to the Critical Element Pathway by CMS. You can Google Ftag 686, Critical Element Pathway, and what I would encourage you is to use that tool as a team investigation to ask all the right questions around risk and education and so on to really try to find out where did we miss here, and how can we prevent it from happening again if possible? 

Catherine T. Milne, MSN: Great. I know we're running out of time, so I'll buzz through these next 2 cases really quickly. 79-year-old female, mixed arterial venous disease, lymphedema. So you probably know where I'm going with this is that we sometimes don't know where all our resources are. Lymphedema therapists are really hard to find, and there's not enough of them. And not only that, wound care providers don't appreciate lymphedema enough. And clearly, primary care doesn't either. When I talk with people, a lot of primary care students come running through and they've never heard of lymphedema. So when you tell them, it's great awareness. I had the cardiologists come to me and say, “Hey, can you give a lecture on lymphedema? Because I'm getting all these referrals from primary care,” or to manage their lower extremity edema, and it's lymphedema. All the diuretics in the world won't help these people, so we need to start educating our primary care docs. So find out what resources you actually have. You can see just using the physical therapist who's also a lymphedema therapist at engaging the patient, we were able to close her. 

So, which rules you work best? I think you have to figure out what's good for your organization and your team. Some people like regular updates that are very brief. Some people like safety huddles or talk-throughs. Some people like sharing and celebrating. And some people like team-building activities where they can also move patients forward through the system but also enhance the team itself. 

And then this is my last case. She's a non-healing abdominal wound. And you can see her diagnosis here, bipolar disease, and she's living with supervised home health with medication administration, non-healing abdominal wound from a chole 3 years ago. It would open, close, open, close. This is what it looks like. 

We did good wound hygiene, we gave some ORC/collagen, we put a foam dressing on it, and it got better, right? And then closed at 8 weeks. 

And then Mother's Day came along, it's open again. So we do the same treatment since it was successful. 

Week 8, she’s getting better; 14, it's healed. So we're patting ourselves on the back. Next Christmas, next Mother's Day, again and again and again. And then it just hit us as a team. You know what? There's something going on with this person at holidays. So we contacted our psych APRN, and she made adjustments. So sometimes we have to think out of the box and think about people that we wouldn't ordinarily have with us in our team and use them when we think we can use them. 

So to summarize, before we take your questions, because Jeanine and I are really excited about that. Engage your patients, use a multidisciplinary patient-centric care, what is important to them. And then look outside your normal circle. And with that, thank you very much. And Jeanine and I are looking forward to your questions. 

Jeanine McGuire, MPT, CWS: That was great, Cathy. We have a couple of questions. The first one is about patient engagement. So let me premise this by saying we both understand that when it comes to patient engagement and their behaviors with engagement, consistency in our messaging from a team perspective and staff consistency are both drivers to improving that engagement. So we agree with that. But today, particularly in skilled nursing, home health, a lot of areas in health care, we have a huge issue with turnover. So the ability for a patient to truly understand the wound type, to have that health literacy around the connection of chronic disease and their wound type, and then importantly, to motivate them. Do you have any strategies in mind or suggestions on how we can engage patients with the staffing issues that we have today and the lack of consistency that that renders in our messaging? 

Catherine T. Milne, MSN: Wow, Jeanine. Thank you, first of all, for having me today, and I want to thank PAWSIC and our sponsor. If I had the answers to that question, I don't think I would be here. It's a very challenging subject to even attempt to try to solve. So I like to think about what does your organization, what strengths does your organization have? 

So let's say you do safety huddles in the morning, or maybe you do walking rounds, or maybe at care planning meetings, then that's when you start saying, “This is the message we are going to be saying to this patient.” That could be one model. Another model is having one assigned treatment nurse or wound nurse or infection control nurse. Identify that one person who's always going to doing the wound care, giving that same message, and then that person then talks to the nursing aides and therapy and so on and so forth. 

But the most important one that I think is the easiest to implement is having rounds with a multidisciplinary team. Everybody's there. Everybody's hearing the same message, including the patient. And so there can be back and forth. And if the patient has a concern, "Oh, I don't think I can do this," or, "I have a barrier here," everybody hears what the patient is saying too. So we are also engaged as the patient is engaged. So I think you really need to look at your organization and see what will work best for you. But again, those team rounding and getting the aides there and maybe the person who cleans the room, all those people are very important. So they hear the same message. 

Jeanine McGuire, MPT, CWS: I love that. So three things I heard there. Number one, when you don't have consistency in staff before you walk into that patient's room at bedside, before you go in, you all agree on the message together that you're going to be conveying. That's one. Number two, perhaps assign a care leader. And three, and it sounds like most importantly, is round as a team and the team extends beyond health care providers. It could be housekeeping, it could be the patient's POA, whomever, but most importantly, the team. So excuse me, the patient. So they're included in that conversation as well. Does that capture the three things? 

Catherine T. Milne, MSN: That's perfectly said. Thank you so much. 

Jeanine McGuire, MPT, CWS: Now, we have another question that piggybacks on. It says, “Curious about us as consultants for patients and how ultimately the patient decides their course of care.” There is a patient with the venous leg ulcer who absolutely refuses compression.” And they said “The patient cites hypertension as a rationale and insists we do a daily home visit to manage her exudate. How do we allow the patient to have autonomy while working within our resources and in accordance to best practice?”

Catherine T. Milne, MSN: So again, I think you can't change a patient's behavior overnight. I think, you have to examine what's really causing that behavioral choice. Is it that the patient is really lonely and really wants to have somebody come into their home every single day to make sure they're safe, that they aren't on the floor? So it's really getting to the bottom of the choice in behaviors. And then trying to figure out what's going on but also doing a contract. Sometimes we have to do a patient contract because the insurance company says, “Sorry, you get two minutes, your two visits a week.” And then you have to be very frank with the patient and say, “We can't do this, so let's figure out the best way we can given the restrictions upon you and upon us as the agency.” 

Jeanine McGuire, MPT, CWS: Excellent.

Catherine T. Milne, MSN: So it doesn't happen overnight. 

Jeanine McGuire, MPT, CWS: Yeah. And we have to wrap it up after this, so one really quick question. In our case study, case study number one, your case study, I said, “Well, that's not pressure,” but it was pressure, right? And I threw that out there so we could all talk about this. In 30 seconds or less, When you have a team member that says it's wound type A and it's wound type B, how do you handle that? 

Catherine T. Milne, MSN: Yeah, so you don't handle it in front of the patient. That's number one. And you can handle it one-on-one, which is usually the best way to do it because you don't want to call out and embarrass a team member. But then if it doesn't resolve, then you really need to get the team together.

Jeanine McGuire, MPT, CWS: Yeah.

Catherine T. Milne, MSN: Because maybe it wasn't pressure, right? 

Jeanine McGuire, MPT, CWS: Yeah.

Catherine T. Milne, MSN: Maybe somebody, yeah. So you have to examine people's perceptions and why they came to that conclusion. 

Jeanine McGuire, MPT, CWS: Thank you. Excellent.